Nursing Elites

1. An adolescent client is admitted to the psychiatric unit for self-harming behaviors. Which of the following is a priority nursing intervention?

• A. Assess the client’s suicidal ideation.
• B. Educate the client about healthy coping mechanisms.
• C. Encourage family therapy sessions.
• D. Provide a safe environment free of potential self-harm tools.

Correct answer: D

Rationale: The priority nursing intervention for an adolescent admitted for self-harming behaviors is to provide a safe environment free of potential self-harm tools. This intervention aims to prevent immediate harm to the client. Assessing suicidal ideation is important but ensuring physical safety takes precedence. While educating about healthy coping mechanisms is crucial for long-term management, immediate safety is the priority. Family therapy sessions are beneficial for holistic care but are not the immediate priority when the client's safety is at risk.

2. While working with a male client at a community mental health center, the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement?

• A. Prevent the client from going into the kitchen until the hallucination subsides.
• B. Report the behavior to the client’s case worker to inform the family.
• C. Assign a UAP to stay with the client continually.
• D. Document the behavior in the client’s record and notify the HCP.

Correct answer: A

Rationale: The most crucial intervention for the RN to implement in this scenario is to prevent the client from accessing the kitchen where potential means of self-harm are available until the hallucination subsides. This immediate action is necessary to ensure the client's safety. While reporting the behavior to the client's case worker for further support is important, addressing the immediate risk of harm takes precedence. Assigning a UAP to stay with the client continually is valuable for ongoing monitoring but is secondary to ensuring immediate safety. Documenting the behavior in the client's record and notifying the healthcare provider are essential steps in the care process; however, they should follow actions taken to ensure the client's immediate safety.

3. A male client with schizophrenia tells the RN that he is being watched and that the television is speaking directly to him. Which response by the RN is appropriate?

• A. “The television cannot speak to you.”
• B. “That sounds very frightening for you.”
• C. “You should ignore the television.”
• D. “Why do you think the television is talking to you?”

Correct answer: B

Rationale: Option B is the correct response because it acknowledges the client's feelings and demonstrates empathy. By stating that the situation sounds frightening, the RN validates the client's experience without denying or reinforcing the delusion. This approach helps build rapport and trust with the client, which is essential in therapeutic communication. Options A and C are dismissive and may invalidate the client's experience, potentially worsening the trust relationship. Option D is confrontational and may make the client defensive, hindering effective communication and rapport-building.

4. A healthcare professional is preparing to provide medication education to a client who has just been prescribed an antipsychotic medication. What should the healthcare professional include in the teaching plan?

• A. “You should have regular eye exams.”
• B. “It is important to avoid caffeine while on this medication.”
• C. “You may experience dry mouth and blurred vision.”
• D. “You should increase your intake of vitamin C to prevent side effects.”

Correct answer: C

Rationale: The correct answer is C. Antipsychotic medications often have anticholinergic side effects like dry mouth and blurred vision. Teaching the client about these potential side effects is essential for their understanding and management. Regular eye exams (Choice A) are not specifically related to antipsychotic medications. While avoiding caffeine (Choice B) might be a general good practice, it is not a specific side effect of antipsychotic medications. Increasing vitamin C intake (Choice D) is not a standard recommendation for preventing antipsychotic medication side effects.

5. A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the nurse to take?

• A. Assure the client that she will be seen by a healthcare provider today.
• B. Recommend that the client speaks with a social worker.
• C. Ask the client if she feels comfortable sharing why she is being stalked.
• D. Offer the client a safe place to relax before interviewing her.

Correct answer: D

Rationale: The most important action for the nurse to take in this scenario is to offer the client a safe place to relax before interviewing her. The client's disheveled appearance and foul body odor suggest she may be in distress or facing challenging circumstances. By providing her with a safe and comfortable environment to relax, the nurse can help alleviate some of her distress and establish trust. This approach is crucial as the client is already feeling scared due to being stalked, indicating underlying mental health concerns. Assuring the client that she will be seen by a healthcare provider today (choice A) may not address her immediate need for safety and comfort. Recommending she speaks with a social worker (choice B) may be beneficial later but does not address the immediate need for a safe space. Asking the client if she feels comfortable sharing why she is being stalked (choice C) is not appropriate as the priority is ensuring her safety and comfort first.

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